Risk for Fluid Volume Deficit
related to
- fluid intake and output,
- excessive loss: vomiting, bleeding, diarrhea
- decrease in fluid intake: nausea, anorexia
- increased need for fluids: fever, hypermetabolic.
Purpose : the volume of fluid being met
Expected outcomes:
- Adequate fluid volume
- The mucosa moist
- Vital signs are stable: BP 90/60 mm Hg, pulse 100x/menit, RR 20x/menit
- Pulse palpated
- Urine output 30 ml / hour
- Capillaries and refill less than 2 seconds
related to an agent of physical injury
Purpose: pain is resolved
Expected outcomes:
- The patient stated the pain disappeared or controlled
- Shows the behavior of pain management
- Looks relaxed and able to rest, sleep
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